Mental Health is Public Health

The need is huge and unmet, say experts, and we ignore it at our peril.

In an editorial published at the start of 2014, New York Times columnist Nicholas
Kristof argued that mental health is one of the most crucial and “systematically neglected”
topics we need to address as a society.

“One-quarter of American adults suffer from a diagnosable mental disorder, including
depression, anorexia, post-traumatic stress disorder and more,” Kristof wrote. Such
disorders are the leading cause of disability in the United States and Canada, he
added, and pose a greater threat to our well-being than Al Qaeda terrorists. But in
polite society a code of silence persists, and Kristof called on his peers in the
media to do more to break the taboos surrounding mental health. He also noted the
unjust burden imposed on both children and racial and ethnic minorities by untreated
mental health problems.

Not two weeks after Kristof’s editorial, the New England Journal of Medicine published
an editorial calling for increased global access to “evidence-based treatment and
care” for people with mental disorders. “Arguably the most important reason for action
is the disturbing evidence that people with mental disorders … are subject to some
of the most severe human rights violations encountered in modern times,” the authors
wrote.

What role can—and should—public health play in meeting this immense and largely unmet
need? That’s the question we put to a range of experts. Their answers follow:

Sources:

Nicholas Kristof,“First Up, Mental Illness. Next Topic Is Up to You,” The New York Times (January 4, 2014).

It’s a kind of insanity—a nearly clinical madness—not to provide for mental health
needs in public health policy. People whose mental health challenges are being handled
well live richer and happier lives, so there’s a moral imperative there. But for the
people who are unmoved by that argument, there is an urgent economic one to complement
it. Untreated mental illness is terrifyingly costly: those living with untreated illness
are more likely to manifest somatic symptoms, are less able to care for themselves,
are less likely to participate in the nation’s economy, will struggle to take care
of children whose own behavioral issues generate enormous expense, and may be more
inclined to commit criminal acts. We ignore these populations at our collective peril.”

Andrew Solomon, PhD, author of The Noonday Demon: An Atlas of Depression (2001 National Book Award; 2002 Pulitzer Prize Finalist) and Far from the Tree: Parents, Children, and the Search for Identity (2012 National Book Critics Circle Award)

If we think about how over 70 percent of our $2.8 trillion health care budget in the
U.S. is related to chronic disease, and then we think about how over 75 percent of
chronic disease is related to our behaviors and lifestyles and the decisions we make,
then you start realizing how important mental health issues are to both physical health
and our economy. If public health is truly interested in the root causes of health
and disease, we need to adopt a truer definition of health and pay as much attention
to mental health issues as we do to physical health issues, rather than separate them
as we’ve done up to now.”

Victor Strecher, MPH ’80, PhD ’83, Professor and Director for Innovation and Social Entrepreneurship,
U-M SPH; Author, On Purpose: Lessons in Life and Health from the Frog, the Dung Beetle, and Julia (2013)

One issue we have to think a lot about is capacity. We have some recent survey data
that shows that a majority of primary care physicians don’t think we have adequate
capacity today for adults or children who need mental health services. And inpatient
mental health services aren’t exactly places where health systems make a profit. So
we have to think a lot about how much we value those services, and make sure those
services are available, whether they’re good for the bottom line or not. That’s a
complicated piece—and public health is a huge part of it.”

When I present a statistical analysis involving mental health, I like to say that
mental health is the most endogenous variable ever—it is affected by just about everything,
and it affects just about everything. If you take a narrow perspective, you are almost
sure to miss something important. So a holistic, public health perspective is needed
to understand the determinants and consequences of mental health, and how to improve
mental health. This presents a major challenge for researchers and practitioners—understanding
and influencing mental health is so complicated. The flip side, and the reason I find
this area so exciting, is that there is an opportunity for collaborative public health
approaches to make a major contribution to societal health and well-being.”

Depression afflicts one in every six people. It’s the second costliest disorder in
the United States, and according to the World Health Organization, the costliest disorder
in most of the developed world. When you have something like this that is prevalent,
disabling, costly, and potentially lethal, you should be doing something about it.
So it is a public health issue.

Study after study shows that we should be screening for depressive illnesses at the
age of onset, which is typically between 15 and 24, rather than waiting for them to
get progressively worse. Almost always, major medical illnesses are best treated in
the early stages—look at diabetes. If you ask where a marriage between health care
delivery and public health has really shined, it’s in diabetes prevention and management.

If we’re going to have breakthroughs in mental health, we have to shift to an epidemiological
perspective and find out where the people are who need the help. We need to recognize
early onset and intervene when it can be most helpful. We need to develop biomarkers
and lab tests to identify who is at risk. This is a quintessential public health problem—but
it’s also a pediatrics problem, an internal medicine problem, a school and a workplace
problem. This is why we need an integrative model, which is a public health model.
If anything, public health people are leading the charge, saying we can do this differently.
I don’t hear much of that coming from the general health care delivery system.”

It’s been clear to me since I began doing my early work in psychiatric epidemiology
that many of the things that cause emotional distress or pain are the large social
factors that impinge upon people’s lives. Something as basic as exposure to stress
or to stressful life events—including social problems—is an obvious precursor to what
we call mental health and well-being. And those are all very much in the public health
paradigm. When one thinks about prevention in public health, social stressors are
some of the primary targets if you want to try to create a better sense of emotional
well-being for people—especially vulnerable populations.”

In 2009, I had the privilege of serving on an Institute of Medicine committee that
issued a report on the prevention of mental illness and problem behaviors in children,
youth, and families. We found that across the developmental span of childhood, from
preconception on, there are effective interventions that can have a lifelong impact.
Early in life, home nurse visitation, high-quality center-based care such as Head
Start, and high-quality pediatric care make a huge difference, as do targeted interventions
during the school years. Moving into adolescence, there’s good evidence we can prevent
substance abuse and episodes of depression and even possibly stave off psychotic episodes
and schizophrenia through community awareness and by heeding very early warnings signs,
or in some cases using cognitive behavior therapy and antipsychotics.

When you see so many kids already addicted to drugs or attempting suicide, you say
to yourself, we have to go further upstream. We have to intervene before things become
so terrible. Kids who have poor physical and mental health outcomes very often have
parents who are depressed, so we can also intervene effectively to strengthen parenting.
Investing dollars in prevention makes sense. There’s a lot that we could do if we
include mental health in the broad public health framework. Public health needs to
embrace mental health issues the way it has physical health issues.

One of the things we learn about in public health is that if you test for it, you
have to do something about it—you don’t just test and do nothing. With so many health
care organizations now embracing the patient-centered medical-home model of care,
pediatricians and primary care physicians are doing more screening. But there aren’t
enough psychiatrists to go around, so we need an integrated, interdisciplinary, public-health
approach to not only treatment, but above all prevention—screening, education, and
outreach.”

My father struggled with bipolar disorder for ten years. When he finally got the treatment
he needed, he was able to lead a happy and successful life again. To help ensure people
get early treatment, we must reduce the stigma around mental illness and increase
the funding for services in the community. That’s why I authored the ENHANCED Act
to establish national centers of excellence, based on the great work already underway
at the U-M Comprehensive Depression Center, to increase the focus on critical research
and better treatment of depression and bipolar disorders. My Excellence in Mental
Health Act would go even further to help increase the availability of treatment in
communities and improve the quality of care offered. Public health has a vital role
to play in all of these efforts.”

U.S. Senator Debbie Stabenow(D–Michigan)

First, some of the best epidemiologic studies say that in any one year, approximately 40
percent of the U.S. population may be affected by significant psychiatric illness—including
anxiety disorders, depression and bipolar disorder, schizophrenia, and alcohol/drug
abuse or addiction. The numbers are more or less the same in the rest of the developed
world.

Second, access to treatment is inadequate. Even in the U.S., only about 20 percent of the
people who have depression—to take just one example—receive adequate treatment. As
with many illnesses, the first treatment does not necessarily produce the desired
outcome. So treatment adherence and good follow-up are major needs—and both are directly
linked to outcomes and costs.

Fourth, the World Bank predicts that by 2020 depression will be the number one global eco-
nomic burden of any disease.

Fifth, it’s not uncommon for patients who present to a physician or are admitted to an
emergency room to have both a medical and a psychiatric problem. And when that happens,
the psychiatric component of the patient’s clinical picture is generally not addressed
at the same level as the medical component.

So mental health is a major health problem, which means it’s a public health problem.
But it’s not generally viewed as a public health priority, in large part because of
stigma, I believe, but also because many health professionals are unaware of data
like this.

Only in the last six years have international and national health organizations recognized
that:

Mental illnesses are the second largest contributor to the worldwide disease burden;

Mental health conditions should be provided with the same out-of-pocket costs to individuals
as traditional medical conditions;

The provision of mental health services is an essential benefit under the Affordable
Care Act.

Public health has always taken a lead in community education, screening for illness
and at-risk behaviors, linking individuals and communities to care, helping to measure
the acute and chronic disease needs of communities, and implementing short- and long-term
interventions to mitigate the resulting harm. Public health has also promoted the
innovative use of health information technologies for the exchange of critical data
on disease and its social determinants. By viewing mental health as a key component
of public health, one can see the immense potential for rapid, integrated, coordinated
mental health care within the context of primary care.

As advances in U.S. public health grow and progress, it is critical that we embrace
mental health conditions as matters of public health, rather than simply as clinical
concerns. Just as we encourage individuals to pursue treatment for common or chronic
diseases, we should advocate to change attitudes and help-seeking behaviors related
to mental health—for the benefit of society as a whole.

A prime example is the U.S. Department of Veterans Affairs’ Make the Connection initiative
(maketheconnection.net), a public health education campaign to connect veterans and
their families with mental health information and services—and help them discover
ways to live more fulfilling lives. On the website’s educational pages, veterans and
civilians can learn about the types of symptoms and conditions veterans may experience,
without unnecessarily labeling or stereotyping veterans.

While Make the Connection encourages veterans to reach out and overcome their life
challenges, the campaign also inspires cultural change by showing all viewers that
treatment is available—and it works. On both an individual and a population level,
Make the Connection is designed to change perceptions about mental health treatment
and is leading the charge to move beyond mental health stigma to promote health and
wellness.

We know that those who suffer from mental health issues have high rates of co-morbid
conditions, such as cardiac disease, and are high utilizers of the medical care delivery
system. And, more and more, we know that there is a significant biological component
to many mental health conditions.

And yet the media and others, including many health professionals, persist in making
an artificial distinction between “mental health” and “physical health.” It is time
that we stop making this distinction.

Mental health parity is a step in that direction. But, until we end the way those
of us who work in health care speak about these conditions, stigma related to mental
illness will continue. Until we end the artificial distinction between physical and
mental health, research into causes and cures will be limited, and not enough practitioners
will choose to work in this field. As long as some see mental health issues as a sign
of “weakness” and not a clinical condition, people most in need will not seek care.
Isn’t it time for public health to lead the way in changing how we view and talk about
these devastating diseases?

When it comes to mental health, we’re more or less where the war on cancer was in
the early 1970s. The brain is the most complicated of all of our organs by many orders
of magnitude, and we are just now getting the biological tools to allow us to interrogate
it at the molecular level and to use imaging techniques to see the brain in action.
So the opportunity to make progress against major psychiatric disorders is at hand.
That doesn’t mean it’s going to happen quickly, but it means hard science has a beginning
foothold in our field. Up to now we’ve been developing treatments by chance and learning
to use them by experience, but we haven’t had a rational understanding of what goes
on in the brain. Now that we’re getting that understanding, we have the potential
for more rational treatment. Eventually we’ll get to prevention.

If you care about public health, you’ve got to care about mental health. As a group,
psychiatric disorders cause more social and financial cost worldwide than any other
group of disorders—and they’re closely related to such major causes of disability
and death as heart attacks, strokes, diabetes, and Alzheimer’s disease.

With the Affordable Care Act, we’re going to see more people coming into the system.
What’s it going to mean? We’re going to need to figure out new and collaborative models
of care—the idea of a therapist sitting with an individual patient may no longer be
the norm. Public health could help us make the shift to a more population- and prevention-based
approach to mental health.

Who's Mental Health Action Plan

Adopted in May 2013 by the 66th World Health Assembly, the World Health Organization's
Comprehensive Mental Health Action Plan 2013–2020 sets new directions for mental health,
among them a central role for the provision of community-based care and a greater
focus on human rights. The plan's four main objectives are: